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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50426/psn-pdf
    January 01, 2020 - Community pharmacy medication review, death and re- admission after hospital discharge: a propensity score- matched cohort study. September 4, 2019 Lapointe-Shaw L, Bell CM, Austin PC, et al. Community pharmacy medication review, death and re- admission after hospital discharge: a propensity score-matched cohort s…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42883/psn-pdf
    September 01, 2016 - Are we heeding the warning signs? Examining providers' overrides of computerized drug–drug interaction alerts in primary care. September 1, 2016 Slight SP, Seger DL, Nanji KC, et al. Are we heeding the warning signs? Examining providers' overrides of computerized drug-drug interaction alerts in primary care. PLoS …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46504/psn-pdf
    February 22, 2018 - How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study. February 22, 2018 Bradley EH, Brewster AL, McNatt Z, et al. How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study. BMJ Qual Saf. 2…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38116/psn-pdf
    February 18, 2011 - Factors associated with intern fatigue. February 18, 2011 Friesen LD, Vidyarthi A, Baron RB, et al. Factors associated with intern fatigue. J Gen Intern Med. 2008;23(12):1981-6. doi:10.1007/s11606-008-0798-3. https://psnet.ahrq.gov/issue/factors-associated-intern-fatigue Reducing duty hours for physicians in train…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41535/psn-pdf
    December 31, 2014 - Understanding and preventing wrong-patient electronic orders: a randomized controlled trial. December 31, 2014 Adelman JS, Kalkut GE, Schechter CB, et al. Understanding and preventing wrong-patient electronic orders: a randomized controlled trial. J Am Med Inform Assoc. 2013;20(2):305-310. doi:10.1136/amiajnl- 201…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60977/psn-pdf
    January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication September 30, 2020 Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication The Case A 65-year-old woman co…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849661/psn-pdf
    June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery June 28, 2023 Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023. https://psnet.ahrq.gov/web…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49580/psn-pdf
    March 21, 2009 - Medication Reconciliation Victory After an Avoidable Error March 21, 2009 Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error The Case A 91-year-old woman, previously active and indepen…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33705/psn-pdf
    January 01, 2011 - Risk Management and Patient Safety December 1, 2010 Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety Perspective In 1990, a Harvard-based research team reported the incidence of medical errors …
  10. psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
    September 23, 2024 - Rescue Improvement Conference Innovation Summary Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL July 23, 2024 View more articles from the same authors. Innovation Contact …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33581/psn-pdf
    December 15, 2024 - Medication Errors and Adverse Drug Events December 15, 2024 Medication Errors and Adverse Drug Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect cu…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/864868/psn-pdf
    March 27, 2024 - Inpatient Transitions of Care: Challenges and Safety Practices March 27, 2024 Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. PSNet [internet]. 2024. https://psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices Background Transitions of care occur …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849598/psn-pdf
    May 31, 2023 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis May 31, 2023 https://psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve- management-sepsis Summary Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidiscip…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845360/psn-pdf
    March 29, 2023 - Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety rounds. March 29, 2023 Hayes M, Wheeling D, Kaul-Connolly S. Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety rounds. J Nurs Car…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41451/psn-pdf
    October 19, 2012 - Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians. October 19, 2012 Sarkar U, Bonacum D, Strull W, et al. Challenges of making a diagnosis in the outpatient setting: a multi- site survey of primary care physicians. BMJ Qual Saf. 2012;21(8):641-648. doi:10.113…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41187/psn-pdf
    October 16, 2012 - A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. October 16, 2012 Avery A, Rodgers S, Cantrill JA, et al. A pharmacist-led information technology intervention for medication errors (PINCER): a …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46893/psn-pdf
    March 21, 2018 - Vital signs: trends in emergency department visits for suspected opioid overdoses- United States, July 2016- September 2017. March 21, 2018 Vivolo-Kantor AM, Seth P, Gladden M, et al. Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses - United States, July 2016-September 2017. MMWR M…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39549/psn-pdf
    March 22, 2011 - The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit. March 22, 2011 Trbovich PL, Pinkney S, Cafazzo JA, et al. The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simul…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43042/psn-pdf
    December 18, 2014 - Introduction of surgical safety checklists in Ontario, Canada. December 18, 2014 Urbach DR, Govindarajan A, Saskin R, et al. Introduction of Surgical Safety Checklists in Ontario, Canada. New Engl J Med. 2014;370(11):1029-1038. doi:10.1056/nejmsa1308261. https://psnet.ahrq.gov/issue/introduction-surgical-safety-ch…
  20. psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
    December 18, 2024 - Exercise is one of those interventions that reduces fall risks by 23%, so it is a good one to encourage

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